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Post-traumatic stress disorder

Post-traumatic stress disorder (PTSD) is a psychological and physical condition that can be caused by extremely frightening or distressing events.Brought to you by NHS Choices

Overview

Introduction

PTSD can occur after experiencing or witnessing traumatic events such as military combat, natural disasters, serious accidents, terrorist attacks, violent deaths and personal assaults, including rape and other situations in which the person felt extreme fear, horror or helplessness.

Many people develop PTSD because someone close to them died suddenly (around 40%). Around 30% of people exposed to such a stressful event will develop PTSD.

PTSD can affect anyone. It's common and affects around 5% of men and 10% of women some time in their life. It can happen at any age, including in childhood. An individual with PTSD often relives the experience through nightmares and flashbacks, and has problems with concentrating and sleeping, with feelings of isolation and detachment from life. These symptoms can be lasting and severe enough to impair the person's daily life significantly.

Symptoms usually develop immediately or within three months of a traumatic event, although, occasionally, they do not begin until years later.

PTSD has been called shell shock or battle fatigue syndrome because it first came to prominence in the First World War, with soldiers' memories of the trenches. It has only recently been recognised that traumatic events outside conflict situations can have similar effects.

The term post-traumatic stress disorder was first used after the Vietnam War. It was formalised in 1980 when it was included in the Diagnostic and Statistical Manual of Mental Disorders, which was developed by the American Psychiatric Association.

Symptoms

Symptoms of post-traumatic stress disorder

Most people who are exposed to a traumatic event experience some of the symptoms of PTSD. However in most cases the symptoms disappear in the days and the weeks following exposure.

Symptoms of PTSD can include:

flashbacks, nightmares or frightening thoughts, especially when exposed to anything reminiscent of the traumatic event,

sweating and shaking,

avoidance of reminders of the event and a refusal to discuss the experience,

numbness and feelings of estrangement or detachment from others,

inability to remember aspects of the traumatic event,

decreased interest in life,

increased consciousness of one's own mortality,

flight/fight syndrome,

problems with concentration,

problems with sleeping,

irritability or outbursts of anger,

hyper-vigilance and alertness to possible danger,

re-experiencing the traumatic event,

feelings of guilt,

long-term behavioural effects,

alcohol abuse,

drug dependency,

failed relationships/divorce,

severe depression, anxiety disorders or phobias,

chronic illness headaches, stomach upsets, dizziness, chest pain and general aches and pains, together with a weakened immune system, and

employment problems.

PTSD often involves periods of symptom remission followed by an increase of symptoms. However, some people will experience severe and unremitting symptoms.

Causes

Causes of post-traumatic stress disorder

It is not yet completely understood why certain people develop PTSD after a traumatic experience, and others do not. However, there are some risk factors which seem to make PTSD more likely to happen to some people. For example, if you have already had depression or anxiety, or you have not had a lot of support from family or friends, you are more susceptible to the condition.

Having a parent who had a mental health problem or experiencing abuse as a child can also be risk factors.

There may also be a genetic factor involved, so some people will be more likely to develop PTSD. The hippocampus (part of the brain that is important to memory and emotions) appears different in MRI scans in those with PTSD. Researchers believe that changes to the hippocampus are related to memory problems and flashbacks.

Studies have also shown that in people with PTSD, there are abnormal levels of hormones involved in their response to stress. People in danger normally produce natural opiates. These chemicals trigger a reaction in the body when put under extreme stress or into a fight or flight situation. They deaden the senses and dull the pain. It has been found that people with PTSD continue to produce high levels when there is no danger. This may cause them to have feelings of detachment and blunted emotions.

Diagnosis

Diagnosing post-traumatic stress disorder

Your GP can diagnose PTSD by discussing all your symptoms with you. They will need to know various things, such as your feelings, your overall health, and how you are sleeping.

Often they will use a specially-designed questionnaire to help them diagnose PTSD. It can include questions such as: Have you had difficulty remembering the event? or Have you felt distant or cut off from other people?

Treatment

Treating post-traumatic stress disorder

Treatment for PTSD usually begins with a detailed evaluation, and a treatment plan is then tailored to your individual needs. It is never too late to ask for help - PTSD is still treatable years after the traumatic event.

Your GP may feel that you would benefit from seeing a counsellor, a community psychiatric nurse, a psychologist or a psychiatrist. The health professionals that you see should always treat you with sensitivity and understanding, and should explain your treatment plan to you clearly. For treatment to be effective, it is important that you and your family understand that PTSD is a medically recognised anxiety disorder that happens to some people after an extremely traumatic experience.

PTSD is often treated with psychotherapy, medication, or a combination of the two.

Cognitive-behavioural therapy (CBT) includes learning skills that help you to change negative thought processes. It also includes the use of mental imagery of the traumatic event to help you work through the trauma, and to gain control of the fear and distress.

Eye movement desensitisation and reprocessing (EMDR) - this involves making several sets of side-to-side eye movements while recalling a traumatic incident. This appears to help reduce distress for many with PTSD. EMDR helps you to have more positive emotions, behaviour and thoughts.

Medications - the most widely used drug treatments for PTSD are the selective serotonin reuptake inhibitor (SSRI) such as paroxetine. These medications may also be prescribed to help reduce associated symptoms of depression and anxiety and help ease sleep. SSRIs should not be prescribed to the under 18s, although fluoxetine can be used if specialist advice is obtained. Benzodiazepines are effective against anxiety, insomnia and irritability, but are now used with great caution because of the high incidence of substance dependence in people with PTSD. These medicines can, however, rapidly relieve any feelings of anxiety triggered by PTSD.

NICE (National Institute for Health and Clinical Excellence) published guidelines (2005) on the treatment of PTSD:

Mild symptoms of less than four weeks - watchful waiting.

Everyone else should be offered trauma-focused CBT or EMDR on an individual outpatient basis.

Children and young people should be offered trauma-focused CBT adapted for their age and circumstances.

Drug treatments should not be used as a routine first line treatment in preference to trauma-focused psychological treatment, but should be considered in adults who do not wish to take part in psychological treatment.

Debriefing sessions (single sessions focusing on the traumatic incident) should NOT be routine practice. All disaster plans should have a planned psychological response to a disaster, with health care workers having clear responsibilities agreed in advance.

Expert view

Anke Ehlers, clinical psychologist and professor at the Institute of Psychiatry, King’s College London, tells us what she would want to know about PTSD.

I cannot stop awful memories of what happened from popping into my mind. Does it mean I'm having a mental breakdown?Having vivid, frequent memories of an extremely traumatic event is understandably very upsetting. It is, however, a common and well-known response to an extreme experience. It shows that your mind is trying to come to terms with what happened, not that you're going mad or losing control of your thoughts.

When will this stop and can I do anything to make it any better?It takes a few weeks or months for the mind and body to adjust but, for most people, the symptoms of PTSD will decline with time. In the early days after a trauma, it's important to look after yourself by doing simple things, such as eating well, staying active, spending time with family and friends, and keeping up a regular routine. In the following weeks, try doing things that were important to you before the trauma, even if you don't feel like doing much.

What if my symptoms aren't improving? Between 30 and 50% of people with severe PTSD symptoms can become stuck during their natural recovery. A person suffering from PTSD for more than three months after the original event is likely to benefit from one of the forms of psychological or 'talking therapies' indicated in the NICE guidelines. If the symptoms are very severe and strongly interfere with the person’s life, earlier treatment is helpful. PTSD is very treatable and following a course of therapy, the majority of people are no longer disabled by the symptoms.

How could something that happened a long time ago cause PTSD?While it's happening, a trauma is overwhelming and no one can fully grasp what is going on and what it means. As a consequence, a trauma memory is not like a memory of other events, which are processed by the mind and 'filed away', and rarely pop into our minds if we don't want to think about them. Memories of a trauma, however, remain unprocessed and can very easily be triggered. When they come to mind, they appear to be in the present ('flashbacks') rather than from the past. To get over a trauma, a person needs to process the memories.

Wouldn’t talking about the trauma make it worse? Isn’t it better to just try to forget? Unfortunately, just pushing the memories out of one's mind does not work and may make the 'flashback' memories more frequent. PTSD is one of a number of anxiety-related conditions for which special 'talking therapies' are particularly useful. One approach - trauma-focused cognitive behavioural therapy (CBT) - involves talking to a therapist about the trauma and learning how to change your thinking and feeling about it. Working through such memories isn't easy but your therapist will support you and make sure it's not overwhelming.

If you've been diagnosed with PTSD:

Remember that emotional distress after a trauma is perfectly normal.

Give yourself time to get over it.

Let family and friends help take care of you.

If you're struggling, don’t be afraid to speak to a doctor.

Real stories

Andy's story

'I was having three or four flashbacks a day'

In some exceptional cases, the vivid recollection of a trauma can cause distress many years after the incident. Andy, an ex-fire officer, describes his experience of post-traumatic stress disorder (PTSD) and how the right treatment has helped him moved on.

"The event that caused my trauma happened 20 years ago when I was a fire officer. I was in charge of an appliance at a house fire where three people had died and it was my job to bring out their remains.

"A few days later I became distressed and started crying and feeling upset. This strong reaction came as a shock but at the time I said nothing. I think this was partly because I wanted to keep it to myself and not share my emotions with anybody.

"My feelings and thoughts continued to bother me for a few weeks. After a while I decided that, because of my job, being like this was no good and I had to put these emotions to one side.

"These early responses to the trauma were an indication of the huge wave of feelings and sensations that would come back 17 years later, this time in such a way that I couldn’t possibly ignore them.

"I was still a fire fighter. Something had made me remember that terrible event and the feelings it left me with, but like before I tried to push it to the back of my mind. A few days later my colleagues and I were at another house fire, similar to the one in which the family had died. Suddenly I wasn’t there. I was totally wrapped up in a flashback of the original incident and someone had to step in and take over from me.

"From then on I started to become distressed for no real reason. Everything seemed to have an emotional element to it and I felt raw and exposed. I got easily frustrated as well, which made me short-tempered and angry.

"When the distress was at its worst I was having three or four flashbacks a day. I would start to sweat and become very nervous as the events of that day came back. All the smells were there and I could even feel the heat of the fire move around across my face. People who saw me say that sometimes I was moving around, mouthing words, but completely detached from my surroundings.

"That was when it became obvious I couldn’t go on as I was. After some time I managed to get a course of trauma-focused cognitive behavioural therapy with ASSIST, a PTSD charity. They helped me to understand for myself that what I had gone through was outside the limits of normal experience, that none of it was my fault and that there was nothing wrong or crazy about my emotional responses.

"Talking about the fire was uncomfortable at times but it helped me process my memories so that they would stop reappearing as flashbacks. They have gone now, and I am able to get on with my life."

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